Score |
Level of sedation |
Response to stimulation |
Response to command |
Examples of type of complex motor activity |
6 |
Dangerously agitated and uncooperative. |
No external stimulus required to elicit movement. |
Does not calm down when asked. |
Patient pulling at tubes or catheters or thrashing from
side to side or striking at staff or trying to climb out of bed. |
5 |
Agitated. |
No external stimulus required to elicit movement. |
Does not consistently obey commands (eg will lie down when
asked but soon reverts to attempts to sit up) |
Patient attempts to sit up and moves limbs out of bed. |
4 |
Restless but cooperative |
No external stimulus required to elicit movement. |
Obeys commands. |
Patient is picking at sheets or tubes or uncovering self.
|
3 |
Calm and cooperative |
No external stimulus required to elicit movement. |
Obeys commands. |
Patient adjusts sheets or clothes purposefully. |
2 |
Responsive to touch or name |
Opens eyes or raises eyebrows or turns head toward stimulus
or moves limbs when touched or name is loudly spoken. |
|
|
1 |
Responsive only to noxious stimuli |
Opens eyes or raises eyebrows or turns head toward stimulus
or moves limbs in response to noxious stimulus (tracheal suctioning or 5
secs of vigorous orbital, sternal or nailbed pressure) |
|
|
0 |
Unresponsive |
Does not move with noxious stimulus |
|
|
Score |
Level of sedation-agitation |
Response |
7 |
Dangerous agitation |
Pulling at endotracheal tube, thrashing, climbing over bed
rails |
6 |
Very agitated |
Does not calm, requires restraints, bites endotracheal tube |
5 |
Agitated |
Attempts to sit up but calms to verbal instructions |
4 |
Calm and cooperative |
Obeys commands |
3 |
Sedated |
Difficult to rouse, obeyss simple commands |
2 |
Very sedated |
Rouses to stimuli. Does not obey commands |
1 |
Unarousable |
Minimal or no response to noxious stimuli |